 Provider News NevadaNovember 1, 2021 November 2021 Anthem Provider News - NevadaEffective January 1, 2022, continuous glucose monitors (CGMs) will no longer be covered under the medical benefit as durable medical equipment for certain [brand] fully insured groups. For these members, CGMs will only be covered under their pharmacy benefits. This applies to both new prescriptions and refills.
We will notify affected members via mail. Members who need to transfer CGMs from their medical benefit to their pharmacy benefit will need a new prescription from their provider.
Note that some Anthem groups will retain their medical DME coverage for CGMs and these members will have the option of using either the medical or pharmacy benefit. Generally, members receive their CGMs faster when obtained using their pharmacy benefit, so we encourage the use of the pharmacy benefit.
If you have questions, please contact Provider Services.
Healthcare and mental healthcare professionals have a vital role in improving health and wellbeing in our communities by identifying and treating racial trauma and injustice experienced by the individuals we serve. At Anthem Blue Cross and Blue Shield (Anthem), we are committed to addressing racism in our society through open discussions about trauma, injustice, and inequality. These conversations are critical to improving the well-being of all Americans and the communities in which we live and serve.
We can impact the injustice of racism together.
Anthem has partnered with Motivo*, the first HIPAA-compliant digital platform that connects mental health therapists and clinical supervisors, to engage providers and associates in conversations on racial injustice, trauma, and inequality. Together, we are continuing to evolve the conversation and digging deeper on a quarterly basis to keep the dialogue going.
Our racial equity forums focus on:
- Exploring how racism impacts health outcomes.
- Discussing how to identify racism in your practice and how to be an ally to your patients.
- Recognizing implicit bias (we all have it!) and how it affects the care provided to your patients.
- Understanding the impact of prolonged exposure to racism on people of color.
- Providing you with actionable resources to recognize and reduce racism that may exist in your practice.
Since October 2020, Anthem has sponsored four virtual forums: Racial Trauma in America, The Road to Allyship: Playing Your Part in Racial Equity, In Pursuit of Racial Equity: Deconstructing Bias Forum, and Exploring the Impact of Racial Trauma on the Health & Wellbeing of Children.
Please save the date for our next forum:
Equity, COVID, and Holidays: Coping with grief
December 8, 2021
4:00-5:30 PM EST
Register today!
Continuing education credits are available for those who sign up and participate!
Registration information will be sent closer to the date of the forum.
The first step in doing your part in addressing racism is to recognize that it exists.
These conversations may feel uncomfortable at first, and that’s ok – this is how we will make progress together in creating a more just and equitable society.
 We recently offered a series of CME webinars on a variety of topics. If you missed any of them, you can still register for the recorded webinars and earn CME credits. The webinars offer best practices to overcome barriers in achieving clinical quality goals and attaining better patient outcomes. We also expect to offer more live CME webinars in the coming weeks.
- Learn strategies to help you and your care team improve your performance across a range of clinical areas.
- Apply the knowledge you gain from the webinars to improve your organization’s clinical quality.
Attendees will receive one CME credit upon answering required questions at the conclusion of each webinar.
Register here for our upcoming live and on-demand clinical quality webinars!
ATTACHMENTS (available on web): 1391.jpg (jpg - 0.04mb) Beginning with dates of service on or after January 1, 2022, Anthem will be implementing revised claims editing logic tied to Excludes 1 notes from ICD-10-CM 2020 coding guidelines. To help ensure the accurate processing of claims, use ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the Category level that a code can be billed with another range of codes, it is imperative to look for Excludes 1 notes that may prohibit billing a specific code combination.
For assistance in determining proper coding guidance, the following site should be helpful: cdc.gov/nchs/icd/icd10cm.htm
One of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 notes. An Excludes 1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes 1 note. These notes appear below the affected codes – if the note appears under the Category (first three characters of a code), it applies to the entire series of codes within that category. If the Excludes 1 note appears beneath a specific code (3, 4, 5, 6 or 7 characters in length) then it applies only to that specific code.
In ICD-10-CM, when a category includes an Excludes 1 note, it outlines what codes should NOT be billed together. Examples of this code scenario would include but are not limited to the following:
- Reporting Z01.419 with Z12.4
- Z01.41X (encounter GYN exam w/out abnormal findings) has an Excludes 1 note below that includes Z12.4.
- Z12.4 (encounter for screening malignant neoplasm cervix)
- Reporting Z79.891with F11.2X
- Z79.891 (long-term use of Opiates) has an Excludes 1 note after it for F11.2X. F11.2X (Opioid dependence)
- Reporting M54.2 with M50.XX
- M54.2 (Cervicalgia) has an Excludes 1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder)
- Reporting M54.5 with S39.012X and/or M54.4x
- M54.5 (low back pain) has an Excludes 1 note below it which includes; S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain) M51.2X (lumbago due to intervertebral disc disorder)
- Reporting J03.XX with J02.XX, J35.1, J36, J02.9
- J03.- (Acute tonsillitis) has an Excludes 1 note below it which includes; J02.- (acute sore throat), J35.1 (hypertrophy of tonsils), J36 (Peritonsillar abscess)
- Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2, A59.00
- N89 (Other inflammatory disorders of the vagina) has an Excludes 1 note below the category for
- R87.62X(abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia),
- R87.623(HGSIL of vagina), N76.XX inflammation of the vagina), N95.2 (senile [atrophic] vaginitis),
- A59.00 (trichomonal leukorrhea)
Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM codebook to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process as to why the billed diagnoses codes are appropriately used together.
In an ongoing effort to promote accurate claims processing and payment, Anthem Blue Cross and Blue Shield (Anthem) prefers the referring physician name and national provider identifier (NPI)to be included on professional home infusion therapy services claims in field 17 and 17a on CMS1500 claim forms.
Providers should report the referring physician information in accordance with the Anthem guidelines in the EDI Companion Guide for electronically submitted claims.
If you have questions regarding this process, please contact your local network consultant.
Each year, Anthem Blue Cross and Blue Shield (Anthem) performs a review of a sample of our members’ medical records as part of the HEDIS® quality study. HEDIS® is part of a nationally recognized quality improvement initiative and is used by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA) and several states to monitor the performance of managed care organizations.
For 2021, Anthem will begin requesting medical records in January 2022. No special authorization is needed for you to share member medical record information with us, since quality assessment and improvement activities is a routine part of healthcare operations.
HEDIS® review is time sensitive, so please submit the requested medical records within the timeframe indicated in the initial HEDIS® request document.
Ways to submit your records:
- Remote EMR Access Service – New!
As we published in the September edition of Provider News, we now offer the Remote EMR Access Service to providers to submit member medical record information to Anthem. If you are interested in more information, please contact us at Centralized_EMR_Team@anthem.com.
- Upload to our secure portal: Medical records can be uploaded to Anthem’s secure portal using the instructions in the request document.
- Fax: Medical records can be faxed to Anthem using the instructions in the request document.
- Mail: Medical records can be mailed to Anthem using the instructions in the request document.
We appreciate the quality of care you provide to our members. Your assistance is crucial to ensuring our data is statistically valid, auditable and accurately reflects quality performance.
The HEDIS® Electronic Clinical Data Systems (ECDS) reporting methodology encourages the exchange of the information needed to provide high-quality healthcare services.
The ECDS Reporting Standard provides a method to collect and report structured electronic clinical data for HEDIS quality measurement and improvement.
Benefits to providers:
- Reduced burden of medical record review for quality reporting
- Improved health outcomes and care quality due to greater insights for more specific patient-centered care
ECDS reporting is part of the National Committee for Quality Assurance (NCQA’s) larger strategy to enable a Digital Quality System and is aligned with the industry’s move to digital measures.
Click here to learn more about NCQA’s digital quality system and what is means to you and your practice.
ECDS Measures
The first publicly reported measure using the HEDIS® Electronic Clinical Data System (ECDS) reporting standard is the Prenatal Immunization Status (PRS) measure. Health plans used the measure in HEDIS Measurement Year 2020 and reported the results in June 2021.
For HEDIS Measurement Year 2022, the following measures can be reported using ECDS:
- Childhood Immunization Status CIS-E*
- Immunizations for Adolescents IMA-E*
- Breast Cancer Screening BCS-E
- Colorectal Cancer Screening COL-E
- Follow-Up Care for Children Prescribed ADHD Medication ADD-E
- Metabolic Monitoring for Children and Adolescents on Antipsychotics APM-E*
- Depression Screening and Follow-Up for Adolescents and Adults DSF-E
- Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults DMS-E
- Depression Remission or Response for Adolescents and Adults DRR-E
- Unhealthy Alcohol Use Screening and Follow-Up ASF-E
- Adult Immunization Status AIS-E
- Prenatal Immunization Status PRS-E (Accreditation measure for 2021)
- Prenatal Depression Screening and Follow-Up PND-E
- Postpartum Depression Screening and Follow-Up PDS-E
Each year, the CDC encourages healthcare professionals, patients, and families to learn more about antibiotics by promoting U.S. Antibiotic Awareness Week (USAAW). Highlighting the importance of improving antibiotic prescribing and use, USAAW brings these lifesaving drugs to the forefront.
With a focus on helping to fight antibiotic resistance, USAAW asks you to Be Antibiotic Aware1 and share this information with your patients:
- Antibiotics can save lives. When a patient needs antibiotics, the benefits outweigh the risks of side effects or antibiotic resistance.
- Antibiotics aren’t always the answer Everyone can help improve antibiotic prescribing and use.
- Antibiotics do not work on viruses, such as those that cause colds, flu, bronchitis, or runny noses.
- Antibiotics are only needed for treating infections caused by bacteria, but even some bacterial infections get better without antibiotics, including many sinus infections and some ear infections.
- Antibiotics will not make patients feel better if the illness is a virus. Respiratory viruses usually go away in a week or two without treatment.
- If antibiotics are needed, they should be taken exactly as prescribed. Provide information about potential side effects, including those that could result in treatment.
- Antibiotics are critical tools for treating life-threatening conditions.
Each year in the United States, more than 2.8 million infections occur from antibiotic-resistant bacteria. More than 35,000 people die as a result.
Measure up: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)
This HEDIS® measure looks at the percentage of members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event. Visit the NCQA website for exceptions.
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Description
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CPT®/HCPCS/ICD-10
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Acute Bronchitis
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ICD-10: J20.3, J20.4, J20.5, J20.6, J20.7, J20.8, J20.9, J121.0, J21.1, J21.8, J21.9
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Online assessments
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CPT: 98970, 98971, 98972, 99422, 99423, 99457 HCPCS: G0071, G2010, G2012, G2061, G2062, G2063
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Telephone visits
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CPT: 98966, 98967, 98968, 99441, 99442, 99443
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To learn more about antibiotic prescribing and use, visit cdc.gov/antibioticuse.
More than 42 million Americans reach for cigarettes regularly, but almost 70 percent of them say they want to quit. What gives? Maybe the traditional ways to quit smoking, such as going cold turkey or wearing a nicotine patch haven’t worked for them in the past. Thankfully, there are plenty of new ways to kick the smoking habit. Here are five approaches to share with patients who are trying to quit.
Download a Quit Smoking App
There are plenty of downloadable quit smoking apps ready to coach patients along the way. Many former smokers recommend the LIVESTRONG MyQuit Coach, a free app available on iTunes.
Start a Quit Reward Fund
According to a study from The New England Journal of Medicine, putting money on the line can help smokers quit. Researchers found 15.7% of people successfully quit for at least six months when they were offered an $800 reward. Patients can set aside their own money as a deposit that they get back when they successfully quit.
Ask Human Resources about Resources
Many employers offer smoking cessation programs, which offer cash rewards, savings on insurance or other perks for not taking a puff. According to the American Lung Association, up to 57% of their smoking cessation program participants reported quitting smoking by the end of the program. Freedom From Smoking®, offered by American Lung Association is an often recommended program.
Quit Smoking with Meditation
For many smokers, the act of lighting up is automatic. But a Yale University study found meditating and practicing mindfulness can cancel that relationship and slash cravings. Recommend a mobile app like Stop Smoking – Mindfulness Meditation App to Cessation Smoking Support.
Consider Medication
Over-the-counter nicotine patches are designed to lessen withdrawal symptoms and have been a go-to for decades. But if those haven’t worked prescription medications can reduce cravings or make smoking less enjoyable.
Measure Up! Medical Assistance with Smoking and Tobacco Use Cessation (MSC) HEDIS® measure looks at members 18 and older to assess different facets of providing medical assistance with smoking and tobacco use cessation:
- Advising smokers and tobacco users to quit
- Discussing cessation medications
- Discussing cessation strategies
Measure adherence is determined by member response through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey.
ATTACHMENTS (available on web): 1407 image.jpg (jpg - 0.03mb) The Anthem Blue Cross and Blue Shield (Anthem) VYNE Medical electronic medical attachment program has expired. As a result, many claims with electronic medical attachments submitted through VYNE Medical are not aligning properly to their corresponding claim, causing those claims to be denied.
Effective immediately, you should submit medical attachments through Availity to avoid claims denials. Availity allows your organization or clearinghouse to submit attachments through EDI.
If you’re using a clearinghouse to submit claims and associated attachments, please advise them immediately to start using Availity to submit claims and attachments.
To submit a medical attachment with your claim submission, log onto availity.com and select the Claims & Payments tab. To submit medical attachments after you have submitted a claim, log onto availity.com, select the Claims & Payment tab and then select Attachments – New.
If you or your clearinghouse is not enrolled in Availity, the process is simple. Assign an Availity administrator for your organization and visit Availity.com/provider-portal-registration to go through the step-by-step process for enrollment. There is no cost to enroll or use Availity for the many digital functions it enables.
For more information about enrolling in Availity, contact their client services department at 800-282-4548, Monday through Friday, 5:00 a.m. to 5:00 p.m. Pacific Time.
Some time ago, Anthem Blue Cross and Blue Shield (Anthem) introduced the ability to submit claim payment disputes via Availity, for members enrolled in our Anthem Blue Cross Medicaid and Medicare Advantage benefit plans, as part of our more streamlined provider claims payment dispute process. Effective November 20, 2021, providers will now also be able to submit claim payment disputes via Availity for Anthem’s Commercial lines of business.
As a reminder, unlike inquiries about claims status, provider disputes, or requests for additional information, provider claim payment disputes occur after a claim is finalized, and a provider disagrees with the claim payments Anthem has issued. Some examples include claim disputes regarding manual processing errors, contract interpretation, reduced payments, code editing issues, Other Health Insurance denials, eligibility issues, timely filing issues *, and so forth.
Anthem’s streamlined provider claim dispute process utilizing Availity across all Anthem lines of business, allows a more cohesive and efficient approach for providers when:
- Filing a claim payment dispute.
- Sending supporting documentation to Anthem.
- Checking the status of a claim payment dispute.
- Viewing the history of a claim payment dispute.
*Reminder: we will consider reimbursement of a claim that has been denied due to failure to meet timely filing if you can:
- provide documentation that the claim was submitted within the timely filing requirements
or
- demonstrate good cause exists.
Reminder on how the provider claim payment dispute process works
For Anthem, the provider claim payment dispute process consists of the following:
Commercial Claims Payment Dispute: A written notice to Anthem challenging, appealing, or requesting reconsideration of a claim or clinical determination that has been denied, adjusted, contested, or seeking resolution of a contract dispute; or disputing a request for reimbursement of an overpayment of a claim.
Providers may submit the claim payment dispute in writing effective November 20, 2021, via Availity; providers are encouraged to submit all commercial disputes via Availity.
When submitting a claim payment dispute for commercial claims, please include as much information as you can including but not limited to the following:
- A clear explanation of the basis for which the Provider or Facility believes the payment amount should be
- Whether the request for reimbursement is for the overpayment of a claim, contest, denial, adjustment, or other action
Please refer to the Provider Manual for additional details.
Anthem will issue a written determination stating the pertinent facts and explaining the reasons for its determination within 60 working days after the date of receipt of the dispute.
Submitting commercial claim payment disputes in writing
When submitting a claim payment dispute in writing, providers must include the Claim Information/ Adjustment Request Form and submit to:
Anthem Blue Cross and Blue Shield
700 Broadway
Denver, CO 80273
Submitting claim payment disputes via Availity — preferred method, as of November 20, 2021
For step-by-step instructions to submit a claim payment dispute through Availity:
- Log into Availity at availity.com.
- Select Help & Training | Find Help.
- Under Contents, select Overpayments and Appeals.
- Select Dispute a Claim.
Through Availity, you can upload supporting documentation and receive immediate acknowledgment of your submission.
Anthem’s review and providers’ other options
Anthem will review the claim payment dispute once received and communicate an outcome in writing or through the Availity Portal. Providers can check the status of a claim payment dispute on the Availity portal at any time.
Once the claim payment dispute is submitted, the decision is final. A claim payment dispute may not be submitted through the provider appeals department (Grievance and Appeals) again. Please refer to the Provider Manual for additional information.
Webinars available
To learn more about the claim dispute tool, register for a live webinar:
- Log in to Availity and select Help & Training | Get Trained.
- Select Sessions and go to Your Calendar to locate a webinar.
- Select View Course and then select Enroll.
- The Availity Learning Center will email you with instructions to attend.
As always, providers can refer to the Provider Manual, as the manual includes additional information about inquiries, and the provider claim dispute process.
Anthem Blue Cross and Blue Shield (Anthem) is pleased to announce a new provider tool to assist physicians in tracking patients that are discharged from the hospital against medical advice (AMA).
This new tool, available through Anthem’s online Availity provider portal, will allow physicians to sign up for admission discharge transfer (ADT) alerts as well as other useful alerts. Once the report is accessed, the discharge type field is where an against medical advice (AMA) event will be identified. This will allow the primary care physician to reach out to the patient and schedule any follow up care as soon as possible.
Anthem encourages the use of this new tool as well as the other reports available. If you are interested in learning more and or obtaining additional information, please contact your assigned Provider Experience representative or visit us at anthem.com/provider/contact-us to view additional contact options.
EnrollSafe is now available as the electronic fund transfer (EFT) enrollment portal for Anthem Blue Cross and Blue Shield (Anthem) providers. Effective November 1, 2021, CAQH Enrollhub is no longer offering EFT enrollment to new users.
CAQH Enrollhub is the only CAQH tool being decommissioned. All other CAQH tools are not impacted.
Benefits of EFT
Electronic funds transfer makes the payment process more convenient and easier to reconcile your direct deposits. EFT is also much faster. You’ll receive your payments up to seven days sooner than through the paper check method. There is no fee to register for EFT via EnrollSafe.
EnrollSafe: Secure and available 24-hours a day
Beginning November 1, 2021, if you need to change an EFT enrollment previously submitted through CAQH, or enroll a new bank account for EFT, visit the EnrollSafe portal at enrollsafe.payeehub.org and select “Register.” Once you have completed registration, you’ll be directed through the EnrollSafe secure portal to the enrollment page. There, you’ll provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub?
Please note if you’re already enrolled in EFT through CAQH Enrollhub, no action is needed. Your EFT enrollment information is not changing as a result of the new enrollment hub.
If you ever have changes to make to your bank account, use EnrollSafe going forward to update your EFT bank account information.
Electronic remittance advice (ERA) makes reconciling your EFT payments easy and paper-free
Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposits – securely and efficiently. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on Availity.
You can retrieve your ERAs directly from Availity. Simply log onto Availity and select Claims and Payments > Send and Receive EDI Files > Received Files folder. When using a clearinghouse or billing service, they will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance Advice under Payer Spaces > Remittance Inquiry tool.
Need further help? EFT and ERA registration and contact information
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Type of transaction
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How to register, update, or cancel
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For registration related questions
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To resolve issues after registration
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EFT only
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Use EnrollSafe
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EnrollSafe help desk at
877-882-0384
Available Monday through Friday 9 a.m. to 8 p.m. ET, except public and/or bank holidays.
E-mail: Support@payeehub.org
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EnrollSafe help desk at
877-882-0384
Available Monday through Friday 9 a.m. to 8 p.m. ET, except public and/or bank holidays.
E-mail:
Support@payeehub.org
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ERA (835) only
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Use Availity
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Availity Support at
800-282-4548
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Availity Support at
800-282-4548
NOTE: Providers should allow up to 10 business days for ERA enrollment processing.
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Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Nevada (Anthem) are pleased to provide you with our updated and new medical policies. Anthem will also be implementing changes to our Clinical Utilization Management (UM) Guidelines that are adopted for Nevada. The Clinical UM guidelines published on our website represent the clinical UM guidelines currently available to all Plans for adoption throughout our organization. Because local practice patterns, claims systems and benefit designs vary, a local Plan may choose whether or not to implement a particular clinical UM guideline. The link below can be used to confirm whether or not the local Plan has adopted the clinical UM guideline(s) in question. Adoption lists are created and maintained solely by each local Plan.
The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.
New Medical Policies effective for service dates on and after February 1, 2022:
- 00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring: This document addresses the use of neuromuscular electrical training of the tongue muscles as a treatment of obstructive sleep apnea (OSA) or snoring.
- Considered Investigational and Not Medically Necessary
- 00058 TruGraf Bleed Gene Expression Test for Transplant Monitoring: This document addresses the TruGraf® blood gene expression test is a blood-based gene expression assay designed to identify transplant recipients who are inadequately immunosuppressed.
- Considered Investigational and Not Medically Necessary
- 00040 Serum Biomarker Tests for Risk of Preeclampsia: This document addresses biomarker testing to identify individuals at increased risk of preeclampsia during pregnancy.
- Considered Investigational and Not Medically Necessary
- 00042 Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy: This document addresses molecular signature testing (PrismRA, Schipher Medicine, Durham, NC) to predict response to Tumor Necrosis Factor inhibitor (TNFi) therapy.
- Considered Investigational and Not Medically Necessary
- OR-PR.00007 Microprocessor Controlled Knee-Ankle-Foot Orthosis: This document addresses the use of a microprocessor controlled knee-ankle-foot orthosis (for example, the C-Brace®, Ottobock HealthCare LP, Austin, TX) that provides support for individuals with lower extremity weakness.
- Provides Clinical Indications for Medically Necessary and Not Medically Necessary criteria
Revised Adopted Clinical UM Guideline effective February 1, 2022:
- CG-DME-44 Electric Tumor Treatment Field (TTF): This document addresses electrical fields known as “tumor treatment fields (TTF)” that are created by low-intensity, intermediate frequency (100–200 kilohertz [kHz]) electric currents delivered to the malignant tumor site by insulated electrodes placed on the skin surface.
- Added Medically Necessary indications for continuation therapy
Medical Policies archived October 6, 2021
- 00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis
- 00085 Antineoplaston Therapy
- 00037 Whole Body Computed Tomography Scanning
Anthem Medical Policies and Clinical UM Guidelines are developed by our national Medical Policy and Technology Assessment Committee. The Committee, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments.
All coverage written or administered by Anthem excludes from coverage, services or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set in Anthem’s medical policies. Review procedures have been refined to facilitate claim investigation.
The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on Anthem’s Web site at anthem.com, and select Providers. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as Your State. Select View Medical Policies & UM Guidelines. Either enter a keyword or code or select the link for the Full List page to search the policy for your inquiry.
Open the attached PDF titled "Nevada Revised Medical Policies and Clinical Guidelines 12.1.21.pdf" to view Nevada's revised medical policies and clinical guidelines
In the January edition of Provider News, we announced updates to the following reimbursement policies:
- Modifier Rules (professional)
- Guidelines for Reporting Timed Units for Physical Medicine and Rehabilitation (professional)
For clarification, these modifier updates align with the codes the Centers for Medicare & Medicaid Services (CMS) has designated as “always therapy” services, and require GN, GO, or GP modifiers for physical therapy, occupational therapy, or speech-language pathology services when billed on a professional claim.
Anthem Blue Cross and Blue Shield (Anthem) covers annual wellness visits and well-woman visits at 100% with no member cost-sharing when provided by in-network providers for members that have ACA-compliant plans. Beginning January 1, 2022, Anthem will encourage some ACA-compliant individual and small group plan members to schedule annual wellness visits or well-woman visits with their physician within the first 90 days of the plan renewal.
Some providers currently require patients to schedule wellness visits or well-woman visits at least one year past their most recent visit. This practice helps ensure a patient does not exceed more than one wellness visit per calendar year. Beginning January 1, 2022, providers can perform the annual wellness visit or well-woman visit for these members, even if it has been less than one year since the last wellness visit. The claim for the wellness visit or well-woman visit will be processed as a preventive care service covered at 100% as long as it is billed accordingly.
Please note this benefit may not apply to all health plans. Providers should continue to verify eligibility and benefits for all members prior to providing services or receiving member copayments, deductibles, or coinsurance.
Blue High Performance Network plans offer access to providers with a record of delivering high-quality, efficient care. BlueHPN® networks first went live on January 1, 2021, in more than 50 cities across the country. Since then, our national customer base has grown, and again this fall, major employers will offer plans with access to our high performance network for the 2022 benefit year.
Member ID cards and other plan material will feature one small change for 2022: BlueHPN is written as a single word rather than two.
As a reminder, BlueHPN is a national network designed from our local market expertise, deep data, and strong provider relationships, and aligned with local networks across the country. These local networks are connected to the national chassis to form a national BlueHPN network. In Nevada, the Pathway HMO network is our Blue High Performance Network. Providers participating in the Pathway HMO will be in-network for any members with Blue High Performance Network network plans.
If you are not sure whether your practice is part of the Pathway HMO network and therefore the Blue High Performance Network, ask your office manager or business office or contact your Anthem network representative. Blue High Performance Network participation will be displayed in provider profiles in our provider directory on January 1, 2022.
As has been true for 2021, you may see patients accessing this network through either a national employer plan, Blue High Performance Network, or large group employer plans with access to the Pathway HMO network. Under these plans, out-of-network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.
Below is a sample ID card for a member from Nevada enrolled in a national employer BlueHPN plan for the 2022 benefit year. Note the new “Blue High Performance Network” logo and “BlueHPN” indicator in the suitcase icon.
Note: The High Performance Network acronym HPN is not used in conjunction or affiliated with any other local organizations known by the same acronym.
ATTACHMENTS (available on web): 1412 image.jpg (jpg - 0.02mb) Effective January 1, 2022, CVS Specialty Pharmacy and IngenioRx Specialty Pharmacy will no longer dispense the brand name drug Botox®. However, Botox will still be available to Anthem Blue Cross and Blue Shield (Anthem) members through other vendors.
Please note:
- This is not a change in member benefits. This is a change in the Botox vendor only.
- If the member is not using IngenioRx Specialty Pharmacy or CVS Specialty Pharmacy to obtain Botox, no action is needed.
- This change will not affect any other specialty pharmacy coverage.
Medical specialty pharmacy benefits
Our members who currently obtain Botox through CVS Specialty Pharmacy using their medical specialty pharmacy benefits must move this prescription by January 1, 2022. Here are the options:
- Providers can purchase Botox for their patients, then supply it to Anthem members. Providers would then bill Anthem for the drug and administration of the drug. This will require a new prior authorization to notify Anthem of this change.
- If the Anthem member’s pharmacy benefit manager is IngenioRx, providers can transition the Botox prescription to receive the drug from any in-network pharmacy using their pharmacy benefits. Transferring the coverage will require a new prescription and new prior authorization.
For questions regarding a member’s medical specialty pharmacy benefits, call Provider Services using the information on the back of the member’s ID card.
Pharmacy benefits manager benefits
Effective January 1, 2022, members who currently obtain Botox through IngenioRx Specialty Pharmacy using their pharmacy benefits must move this prescription from IngenioRx Specialty Pharmacy to another in-network specialty pharmacy that dispenses Botox. If there are refills still available on the current prescription, members can transfer it to the new pharmacy. If not, members will need a new prescription.
For questions regarding a member’s pharmacy benefits, call Pharmacy Member Services using the information on the back of the member’s ID card.
Material adverse change (MAC)
Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our prior authorization (PA) review process.
Please note that the inclusion of a National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Clinical Criteria is available here.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code
|
|
ING-CC-0096*
|
Rylaze(asparaginase erwinia chrysanthemi (recombinant)-rywn)
|
J3590
|
|
ING-CC-0167*
|
Ruxience
|
Q5119
|
|
ING-CC-0167*
|
Truxima
|
Q5115
|
|
ING-CC-0202
|
Saphnelo (anifrolumab-fnia)
|
J3490, J3590
|
|
ING-CC-0203
|
Ryplazim (plasminogen, human-tvmh)
|
J3490, J3590
|
*Oncology use is managed by AIM
Step therapy updates
Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0075
|
Preferred
|
Rituxan
|
J9312
|
|
Riabni
|
Q5123
|
|
Non-preferred
|
Ruxience
|
Q5119
|
|
Truxima
|
Q5115
|
|
ING-CC-0167*
|
Preferred
(no PA or step therapy required)
|
Rituxan
|
J9312
|
|
Riabni
|
Q5123
|
|
Non-preferred
|
Ruxience
|
Q5119
|
|
Truxima
|
Q5115
|
*Oncology use is managed by AIM
Quantity limit updates
Effective for dates of service on and after February 1, 2022, the following specialty pharmacy codes from current and new clinical criteria documents will be included in our quantity limit review process.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code
|
|
ING-CC-0081
|
Crysvita (burosumab-twza)
|
J0584
|
|
ING-CC-0202
|
Saphnelo (anifrolumab-fnia)
|
J3490, J3590
|
Medicare Advantage
On August 21, 2020, November 20, 2020, and June 24, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield (Anthem). These policies were developed, revised, or reviewed to support clinical coding edits.
Visit Clinical Criteria to search for specific policies. If you have questions or need additional information, use this email.
Please see the explanation/definition for each category of Clinical Criteria below:
- New: newly published criteria
- Revised: addition or removal of medical necessity requirements, new document number
- Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive
Please share this notice with other members of your practice and office staff.
Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
|
Effective date
|
Document number
|
Clinical Criteria title
|
New or revised
|
|
November 1, 2021
|
*ING-CC-0201
|
Rybrevant (amivantamab-vmjm)
|
New
|
|
November 1, 2021
|
*ING-CC-0042
|
Monoclonal Antibodies to Interleukin-17
|
Revised
|
|
November 1, 2021
|
*ING-CC-0050
|
Monoclonal Antibodies to Interleukin-23
|
Revised
|
|
November 1, 2021
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
|
November 1, 2021
|
ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
|
November 1, 2021
|
*ING-CC-0102
|
GnRH Analogs for Oncologic Indications
|
Revised
|
|
November 1, 2021
|
ING-CC-0076
|
Nulojix (belatacept)
|
Revised
|
|
November 1, 2021
|
*ING-CC-0077
|
Palynziq (pegvaliase-pqpz)
|
Revised
|
|
November 1, 2021
|
ING-CC-0067
|
Prostacyclin Infusion and Inhalation Therapy
|
Revised
|
|
November 1, 2021
|
ING-CC-0194
|
Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
|
Revised
|
Medicare Advantage
In 2022, Anthem Blue Cross and Blue Shield (Anthem) will be providing members with a new tool to develop an advance medical directive for many of its DSNP Medicare Advantage plans. Anthem has partnered with MyDirectives,* a leader in the industry for electronic advance directives. Information on the service will be provided to members via their Annual Notice of Change (ANOC), Evidence of Coverage (EOC), and Benefit Summaries.
To get started with the Advance Directives program, members will visit the Anthem member website and under the Benefits tab access a link for the Advance Directives program. Selecting this link will take the member to MyDirectives, where they can create a MyDirectives account or link an account if they already use MyDirectives.
MyDirectives has an easy-to-use guide that takes members through a series of questions around their care preferences, establishing of healthcare agents (medical powers of attorney), sharing of information, and more. If they already have a written advance directive, the software allows members to upload copies of their current directive, making it easier to store and share when necessary.
Physicians and hospitals can access a member’s advance directive via healthcare exchanges such as eHealth Exchange, Carequality, and CommonWell Health Alliance.
The benefit and associated links will be live as of the new plan year. We encourage you to speak to your members about the value of establishing an advance directive and support members as they go through the process.
Medicare Advantage
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Availity* serves as our electronic data interchange (EDI) partner for all electronic data and transactions. The Availity EDI processing generates response files for each submitted electronic file and delivers them to the submitter’s Availity mailbox. It is important to review these responses to understand where your claims are in the process.
Electronic file submitter:
- If your organization uses a clearinghouse or vendor, they have an Availity mailbox to submit clients’ files. Availity delivers the responses for claims to the same mailbox, and the clearinghouse or vendor is responsible for returning the results to their clients and resubmitting any files rejected for formatting, interchange, or transaction set errors. The submitter in this scenario is the clearinghouse or vendor.
- If your organization uses a practice management software, an Availity mailbox is set up during initial registration for your electronic file submissions. The submitter is your organization and is responsible for analyzing the responses to verify there are not any file errors or claim rejections that require correction and resubmission within timely filing guidelines.
Availity electronic file process:
- Submit electronic file to Availity: Availity validates for file format and returns file acknowledgments to the submitter’s Availity mailbox. If there are any edits at this point, the entire electronic file will not advance and will require resubmission within timely filing guidelines.
- HIPAA and payer specific edits: The electronic file moves to the next phase, which is HIPAA and business editing. Examples include:
- Valid subscriber ID for the date of service
- Billing and coding validation
If an error occurs at this point, the individual claims with the errors must be corrected, resubmitted as an original claim and do not advance. The claims that do not have an edit will then route to the adjudication systems for second-level edit validation.
- Anthem payer receives electronic file from Availity: For the Medicaid and Medicare lines of business, there is a second level of editing.
Edits for this second level return the Delayed Payer Report (DPR). Only claims that pass will advance for adjudication and will be displayed using Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. If there are edits, the claim requires resubmission within timely filing guidelines.
Electronic responses
File acknowledgment: Indicates whether we receive an electronic file in the correct format and acceptance by Availity.
- Action required: If any errors occur at this stage, the submitter will need to correct and resubmit the entire electronic file to Availity.
Immediate Batch Response (IBR): This report acknowledges accepted claims and identifies claim edits due to HIPAA and business edits. The report also includes claim counts and charges for the electronic file. Availity creates this file prior to routing accepted claims to the adjudication systems.
- Action required for claims with edits: Rejected claims require resubmission within timely filing guidelines and will not advance to the adjudication system that would display Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. Not applicable to denied claims.
Delayed Payer Report (DPR): This report is currently only returned for the Medicaid or Medicare lines of business and contains second-level editing from the adjudication system after Availity has routed claims that passed on the IBR report.
- Action required for claims with edits: Rejected claims would need to be resubmitted and will not display on Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice and paper Explanation of Payment.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local Provider Experience representative, call Availity Client Services with any questions at
800-AVAILITY (282-4548), or call Provider Services at:
- Medicaid: 844-396-2330
- Medicare Advantage: Call the number on the back of the member ID card.
Medicare Advantage
The City of New York has awarded their group retiree business to the Retiree Health Alliance, an alliance between Empire BlueCross BlueShield (Empire) and EmblemHealth. Effective January 1, 2022, approximately 240,000 Medicare-eligible City of New York retirees across the United States will transition to Retiree Health Alliance’s NYC Medicare Advantage Plus plan.
The NYC Medicare Advantage Plus plan is a Medicare Advantage PPO plan that allows retirees to receive services from both in-network and out-of-network providers. Out-of-network providers must be eligible to receive Medicare payments to provide care to NYC retirees. Under this new plan, City of New York retirees will have no difference in cost-share for both in-network and out-of-network services. NYC Medicare Advantage Plus offers the same hospital and medical benefits covered by original Medicare as well as additional benefits original Medicare does not provide, such as an annual routine physical exam, hearing, health and fitness tracker, LiveHealth Online,* and SilverSneakers.*
Retirees enrolled in NYC Medicare Advantage Plus will have access to BlueCross BlueShield Medicare Advantage PPO Network Sharing effective January 1, 2022. Recently, you may have received calls from City of New York retirees inquiring if you are participating or if you accept NYC Medicare Advantage Plus. Retirees may also refer to the new plan as Medicare Advantage Plus or the Alliance.
Currently, City of New York retiree claims are processed by Medicare as primary and then by Empire for facility services or EmblemHealth for professional services as supplemental coverage under the General Health Insurance/Empire Senior Care plan.
Beginning January 1, 2022, under the NYC Medicare Advantage Plus plan, providers will change billing processes as follows:
- Providers should submit all claims (facility, professional, and ancillary) to your local Blue plan:
- For independent clinical laboratories, providers should file to the BCBS Plan where the referring provider is located.
- For durable/home equipment and supplies (D/HME), providers should file to the BCBS Plan where the equipment was shipped to or purchased from in a retail store.
- Providers should not transmit any claims to original Medicare.
- Claims can be submitted electronically or by paper submission (UB-04or CMS-1500 form) to your local Blue plan.
For additional information, review the NYC Medicare Advantage FAQ at anthem.com/da/inline/pdf/abscare-1134-21.pdf.
Medicare Advantage
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Effective November 1, 2021, EnrollSafe will replace CAQH Enrollhub® as the electronic fund transfer (EFT) enrollment website for Anthem providers. As of November 1, 2021, CAQH Enrollhub will no longer offer EFT enrollment to new users.
When you sign up for EFT through enrollsafe.payeehub.org, the new enrollment website, you’ll receive your payments up to seven days sooner than through the paper check method. Not only is receiving your payment more convenient, so is signing up for EFT. What’s more, it’s easier to reconcile your direct deposits.
EnrollSafe is safe, secure and available 24-hours a day
Beginning November 1, 2021, log onto the EnrollSafe enrollment hub at enrollsafe.payeehub.org to enroll in EFT. You’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub?
If you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, after October 31, 2021, use enrollsafe.payeehub.org to update your account.
Electronic remittance advice (ERA) makes reconciling your EFT payment easy and paper-free
Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposit. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on the Availity* Portal. To access the ERA, log onto availity.com and use the Claims and Payments tab. Select Send and Receive EDI Files, then select Received Files Folder. When using a clearinghouse or billing service, they will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance Advice through the Remittance Inquiry app.
Medicaid
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Availity* serves as our electronic data interchange (EDI) partner for all electronic data and transactions. The Availity EDI processing generates response files for each submitted electronic file and delivers them to the submitter’s Availity mailbox. It is important to review these responses to understand where your claims are in the process.
Electronic file submitter:
- If your organization uses a clearinghouse or vendor, they have an Availity mailbox to submit clients’ files. Availity delivers the responses for claims to the same mailbox, and the clearinghouse or vendor is responsible for returning the results to their clients and resubmitting any files rejected for formatting, interchange, or transaction set errors. The submitter in this scenario is the clearinghouse or vendor.
- If your organization uses a practice management software, an Availity mailbox is set up during initial registration for your electronic file submissions. The submitter is your organization and is responsible for analyzing the responses to verify there are not any file errors or claim rejections that require correction and resubmission within timely filing guidelines.
Availity electronic file process:
- Submit electronic file to Availity: Availity validates for file format and returns file acknowledgments to the submitter’s Availity mailbox. If there are any edits at this point, the entire electronic file will not advance and will require resubmission within timely filing guidelines.
- HIPAA and payer specific edits: The electronic file moves to the next phase, which is HIPAA and business editing. Examples include:
- Valid subscriber ID for the date of service
- Billing and coding validation
If an error occurs at this point, the individual claims with the errors must be corrected, resubmitted as an original claim and do not advance. The claims that do not have an edit will then route to the adjudication systems for second-level edit validation.
- Anthem payer receives an electronic file from Availity: For the Medicaid and Medicare lines of business, there is a second level of editing.
Edits for this second level return the Delayed Payer Report (DPR). Only claims that pass will advance for adjudication and will be displayed using Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. If there are edits, the claim requires resubmission within timely filing guidelines.
Electronic responses
File acknowledgment: Indicates whether we receive an electronic file in the correct format and acceptance by Availity.
- Action required: If any errors occur at this stage, the submitter will need to correct and resubmit the entire electronic file to Availity.
Immediate Batch Response (IBR): This report acknowledges accepted claims and identifies claim edits due to HIPAA and business edits. The report also includes claim counts and charges for the electronic file. Availity creates this file prior to routing accepted claims to the adjudication systems.
- Action required for claims with edits: Rejected claims require resubmission within timely filing guidelines and will not advance to the adjudication system that would display Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice, and paper Explanation of Payment. Not applicable to denied claims.
Delayed Payer Report (DPR): This report is currently only returned for the Medicaid or Medicare lines of business and contains second-level editing from the adjudication system after Availity has routed claims that passed on the IBR report.
- Action required for claims with edits: Rejected claims would need to be resubmitted and will not display on Availity claim status, electronic claim status transactions, Availity remittance inquiry, 835 electronic remittance advice and paper Explanation of Payment.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your local Provider Experience representative, call Availity Client Services with any questions at
800-AVAILITY (282-4548), or call Provider Services at:
- Medicaid: 844-396-2330
- Medicare Advantage: Call the number on the back of the member ID card.
Medicare Advantage
This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).
Effective November 1, 2021, EnrollSafe will replace CAQH Enrollhub® as the electronic fund transfer (EFT) enrollment website for Anthem providers. As of November 1, 2021, CAQH Enrollhub will no longer offer EFT enrollment to new users.
When you sign up for EFT through enrollsafe.payeehub.org, the new enrollment website, you’ll receive your payments up to seven days sooner than through the paper check method. Not only is receiving your payment more convenient, so is signing up for EFT. What’s more, it’s easier to reconcile your direct deposits.
EnrollSafe is safe, secure and available 24-hours a day
Beginning November 1, 2021, log onto the EnrollSafe enrollment hub at enrollsafe.payeehub.org to enroll in EFT. You’ll be directed through the EnrollSafe secure portal to the enrollment page, where you’ll provide the required information to receive direct payment deposits.
Already enrolled in EFT through CAQH Enrollhub?
If you’re already enrolled in EFT through CAQH Enrollhub, no action is needed unless you are making changes. Your EFT enrollment information will not change as a result of the new enrollment hub.
If you have changes to make, after October 31, 2021, use enrollsafe.payeehub.org to update your account.
Electronic remittance advice (ERA) makes reconciling your EFT payment easy and paper-free
Now that you are enrolled in EFT, using the digital ERA is the very best way to reconcile your deposit. You’ll be issued a trace number with your EFT deposit that matches up with your ERA on the Availity* Portal. To access the ERA, log onto availity.com and use the Claims and Payments tab. Select Send and Receive EDI Files, then select Received Files Folder. When using a clearinghouse or billing service, they will supply the 835 ERA for you. You also have the option to view or download a copy of the Remittance Advice through the Remittance Inquiry app.
Medicaid
This is a reminder to all providers that we require laterality-specific coding when applicable. Therefore, claims processed on or after October 1, 2021, will be denied when ICD-10-CM laterality coding guidelines are not followed.
In accordance with the International Classification of Disease, 10th Revision, clinical modification
(ICD-10-CM) correct coding guidelines, in which state Medicaid programs follow, we will begin to edit diagnosis in Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue for appropriate laterality billing.
ICD-10-CM diagnosis coding falls under Health Insurance Portability and Accountability Act (HIPAA) correct code sets and they are designed to specifically define laterality (e.g., left, right, unspecified, or exists bilaterally, etc.). Providers are required to submit the defined code in accordance with the condition. The ICD-10-CM guidelines for Coding and Reporting state (for Laterality coding), “Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.”
The ICD-10-CM diagnosis code should correspond to the medical record, CPT® and HCPCS code(s), and/or modifiers billed.
If you have questions about this communication or need assistance with any other item, call Provider Services at 844-396-2330.
Medicaid
The American Cancer Society estimates there will be approximately 1,898,160 cancer cases diagnosed in 2021. That’s the equivalent of 5,200 new cases every day.1 The good news is, patients say they are more likely to get screened when you recommend it. What else can you do to influence cancer screenings?2
- Understand the power of the physician recommendation:
- Your recommendation is the most influential factor in whether a person decides to get screened.
- Patients are 90% more likely to get a screening when they reported a physician recommendation.
- “My doctor did not recommend it,” is the primary reason for screening avoidance.
- Measure the screening rates in your practice; it may not be as high as you think:
- Set goals to get screening rates up.
- Follow the HEDIS® guidelines included in this article to help accurately track your care gap closures.
- More screening doesn’t have to mean more work for you:
- Reach out to us about available member data — We may be able to help identify those members who are due for screenings.
- Develop a reminder system, which has been demonstrated to be effective, to remind you and staff that patients have screenings due.
- Help members access benefit information about screenings to eliminate the cost barrier:
- Log on to Availity.com* and use the Patient Registration tab to run an Eligibility and Benefits Inquiry.
- Members can access their benefit information by logging on to anthem.com/nevada-medicaid and selecting the Benefits tab, or by using Anthem Medicaid mobile app.
Members earn rewards for screenings through the Healthy Rewards Program
Through Healthy Rewards, members receive incentives for completing certain screenings. They can redeem their reward dollars for retail gift cards — just another way we can work together for better health outcomes.
|
Screening
|
Reward
|
Timing
|
|
Breast Cancer Screening (BCS)
|
$50
|
Every two years
|
|
Cervical Cancer Screening (CCS)
|
$50
|
Every three years
|
Measure up: Cancer screening for women HEDIS measure specifications
Organized and continuous screenings along with removal of precancerous lesions can lead to a 60% decrease in cervical cancer.3
Cervical Cancer Screening (CCS) is measured by the percentage of women 21 to 64 years of age who were screened for cervical cancer using one of the following criteria:
- Women 21 to 64 years of age who had cervical cytology performed within the last three years
- Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last five years
- Women 30 to 64 years of age who had cervical cytology/hrHPV co-testing within the last five years
|
Description and code
|
|
Cervical cytology lab test
|
|
CPT®: 88141-88143, 88147, 88148, 88150, 88152-88153, 88164-88167, 88174, 88175
|
|
HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091
|
|
LOINC: 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5
|
|
hrHPV lab test
|
|
CPT: 87620-87622, 87624-87625
|
|
HCPCS: G0476
|
|
LOINC: 21440-3, 30167-1, 38372-9, 59263-4, 59264-2, 59420-0, 69002-4, 71431-1, 75694-0, 77379-6, 77399-4, 77400-0, 82354-2, 82456-5, 82675-0
|
|
Absence of cervix diagnosis
|
|
ICD-10-CM: Q51.5, Z90.710, Z90.712
|
|
Hysterectomy with no residual cervix
|
|
CPT: 51925, 56308, 57530, 57531, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58951, 58953, 58954, 58956, 59135
|
|
ICD-10-PCS: 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ
|
More women in the United States are surviving and thriving after breast cancer than ever before. In fact, in the last 30 years, the breast cancer death rate has dropped an astounding 40%. The decreases are believed to be the result of finding breast cancer earlier through screening, increased awareness, and better treatments.4
Breast Cancer Screening (BCS): The percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer. Compliant members have one or more mammograms any time on or between October 1, two years prior to the measurement year and December 31 of the measurement year.
|
Description
|
CPT/HCPCS
|
|
Mammography
|
CPT: 77061-76063, 77065-77067
LOINC: 24604-1, 24605-8, 24606-6, 24610-8, 26175-0, 26176-8, 26177-6, 26287-3, 26289-9, 26291-5, 26346-7, 26347-5, 26348-3, 26349-1, 26350-9, 26351-7, 36319-2, 36625-2, 36626-0, 36627-8, 36642-7, 36962-9, 37005-6, 37006-4, 37016-3, 37017-1, 37028-8, 37029-6, 37030-4, 37037-9, 37038-7, 37052-8, 37053-6, 37539-4, 37542-8, 37543-6, 37551-9, 37552-7, 37553-5, 37554-3, 37768-9, 37769-7, 37770-5, 37771-3, 37772-1, 37773-9, 37774-7, 37775-4, 38070-9, 38071-7, 38072-5, 38090-7, 38091-5, 38807-4, 38820-7, 38854-6, 38855-3, 42415-0, 42416-8, 46335-6, 46336-4, 46337-2, 46338-0, 46339-8, 46350-5, 46351-3, 46356-2, 46380-2, 48475-8, 48492-3, 69150-1, 69251-7, 69259-0
|
Sexual health is an essential element of overall health and well-being. Many patients want to discuss their sexual health with you, but most of them want you to bring it up. The National Coalition for Sexual Health has published a guide to help physicians feel comfortable about the conversation. Get a copy of the Sexual Health and Your Patients: A Provider’s Guide by clicking on the title or through this website: ctcfp.org.
Chlamydia Screening in Women (CHL) is measured by the percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.
|
Description
|
CPT
|
|
Chlamydia tests
|
CPT: 87110, 87270, 87320, 87490, 87491, 87492, 87810
LOINC: 14463-4, 14464-2, 14467-5, 14474-1, 14513-6, 16600-9, 21190-4, 21191-2, 21613-5, 23838-6, 31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304-5, 43404-3, 43405-0, 43406-8, 44806-8, 44807-6, 45068-4, 45069-2, 45075-9, 45076-7, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 4993-2, 50387-0, 53925-4, 53926-2, 557-9, 560-3, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8, 80360-1, 80361-9, 80362-7, 91860-7
|
Medicaid
Please continue to check Medicaid Provider Communications & updates at anthem.com/nvmedicaiddoc for the latest Medicaid information, including:
|